Provider Demographics
NPI:1972712354
Name:KITSAP EYE PHYSICIANS PS
Entity Type:Organization
Organization Name:KITSAP EYE PHYSICIANS PS
Other - Org Name:DALE N HOLDREN MD INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:N
Authorized Official - Last Name:HOLDREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-377-3703
Mailing Address - Street 1:2655 WHEATON WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3318
Mailing Address - Country:US
Mailing Address - Phone:360-377-3703
Mailing Address - Fax:360-377-9469
Practice Address - Street 1:2655 WHEATON WAY
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3318
Practice Address - Country:US
Practice Address - Phone:360-377-3703
Practice Address - Fax:360-377-9469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003606152W00000X
WAMD00031837207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7071863Medicaid
WAG115133500Medicare ID - Type Unspecified